Remember 2014? Wasnâ€™t that great?
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Intelligencer staffers Benjamin Hart, Ed Kilgore, and Eric Levitz discuss.
Ben: Today, Democratic still-front-runner Joe Biden revealed his campaignâ€™s health-care plan. As many of his rivals endorse transformative changes to the system, mostly under the banner of â€œMedicare for All,â€ Biden is keeping things more modest, expressly building on his old bossâ€™s biggest achievement, the Affordable Care Act. The central plank of Bidenâ€™s proposal is a government-managed public-insurance option; Politico reports that the plan â€œwould also empower Medicare to directly negotiate drug prices, allow the importation of prescription drugs from abroad, and extend tax credits to help tens of millions of Americans buy lower-priced health insurance.â€ Polls show that most Americans like their private health insurance, and Biden clearly doesnâ€™t want to rock the boat that much. What do you make of this proposal?
Ed: Well, itâ€™s perfectly in accord with the overall Biden message of returning America to its positive Obama-era trajectory, and itâ€™s certainly â€œrealisticâ€ in terms of having a better chance of enactment in a Congress controlled by Republicans or narrowly controlled by Democrats.
But itâ€™s pretty far away from the prevailing Democratic Zeitgeist. In a party where â€œMedicare for Allâ€ and â€œMedicare for Mostâ€ are the two main options, a â€œMedicare for the same people who get Medicare nowâ€ menu item isnâ€™t going to be very satisfying.
Eric: The strangest thing about the proposal is that it explicitly aspires to cover 97 percent of Americans. Surely, thereâ€™s a way to tweak it that gets to universal coverage under a reasonable model. Or else the campaign could simply round up in its messaging. Itâ€™s baffling to me that theyâ€™d stake out the position of â€œalmost everyone should be covered.â€
Ed: That was indeed the sort of thing considered â€œprobably good enoughâ€ in 2008. Bidenâ€™s general calculation is that people would be happy to return to that situation now.
Ben: Can you explain that? The 97 percent thing?
Eric: Not really! Haha, itâ€™s just what Bidenâ€™s people are saying. I guess people wonâ€™t be automatically enrolled in the public option, and undocumented immigrants wonâ€™t be eligible for subsidies. I think in practice, 97 percent coverage would be an incredible accomplishment (particularly if that coverage were genuinely affordable and comprehensive). But itâ€™s just weird to own it politically. That said, I think some people are exaggerating the modesty of Bidenâ€™s proposal.
Larry Levitt of the Kaiser Family Foundation told Politico, â€œBuilding on the ACA is the quickest way to get more people insured and improve affordability, while not taking on any powerful health-industry group.â€ That strikes me as patently false. Health-care lobbies are already publicly advocating against a public option. Opposing the governmentâ€™s right to negotiate drug prices is one of Big Pharmaâ€™s top priorities. It is not going to be easy to pass Bidenâ€™s plan. And it would represent a major (and positive) change to the U.S. health-care system if it did make it into law. (Though how major depends on the details of the public option.)
Ed: Itâ€™s important to understand that some of Bidenâ€™s critics are people who pretty much thought Obamacare was a corporate-whore sellout program.
Ben: Bernie Sanders has been clear and unapologetic that his version of Medicare for All would mean abolishing private insurance altogether â€” an enormous disruption to the system but one he thinks will be worth it. Some other candidates have not been as forthright about how, exactly, they would get to universal coverage. Do you think Bidenâ€™s plan is really much different from what a non-Bernie candidate would end up putting on the table if they were to become president?
Ed: Not sure what the next president â€œputs on the tableâ€ is the right yardstick. Itâ€™s what the next president is willing to go to the mat to enact that matters. And whether she or he has a strategy to do that.
Eric: I think Bernie and Warren would feel compelled to put single payer on the table
Ed: Yes, but then what?
Eric: Joe Manchin and Jon Tester move it into the dog bowl.
Ed: Single payer is not going to be enacted by any foreseeably possible 2021 Congress.
Eric: Agreed. And it seems wildly optimistic to think Bidenâ€™s plan would be. America cannot afford universal coverage without eventually coming for the health-care industryâ€™s rents, and the industry knows it.
Ed: So I guess the question is why Biden doesnâ€™t say, which others have, that single payer is the ultimate goal but hereâ€™s something we can do in the meantime.
Eric: I think it makes plenty of political sense for him. Heâ€™s running as the electable moderate. A lot of Democratic primary voters are looking for that.
Ben: Yeah, to me it seems like a pretty sensible move. Sure, lefties will be annoyed, but they werenâ€™t gonna vote for him anyway.
Eric: Heâ€™s never going to be accepted as a progressive champion or even a consensus candidate, so he should own his brand.
Ed: It does put opponents in the uncomfortable position of openly trashing Obamacare, which might even tempt Obama himself to say something.
Eric: Biden did try to play the â€œM4A is a rejection of Obamaâ€™s legacy angleâ€ in his rollout, saying, â€œI understand the appeal of Medicare for All. But folks supporting it should be clear that it means getting rid of Obamacare. And Iâ€™m not for that.â€ But Obama just last year praised Democrats for not â€œjust running on good old ideas like a higher minimum wage but on good new ideas like Medicare for All,â€ which suggests that he doesnâ€™t actually take personal offense at the concept of Democrats running on single payer.
Ben: And of course thatâ€™s a little misleading. Medicare for All has become a nebulous term that does not automatically imply wholesale rejection of Obamacare.
Ed: In any event, the bigger question, which Eric raised a minute ago in the â€œhis own brandâ€ comment, is whether Biden can no longer position himself as a unity candidate and is instead a factional candidate â€” much like Sanders â€” with an electability argument. If so, yeah, grab that moderate lane on this and other issues!
Eric: By his own word, if Obama were emperor, he would establish single payer.
Ed: As I said earlier, it would be easy enough for Biden to say the same thing as Obama, with the emphasis on the â€œin the meantimeâ€ alternative.Â Must be some reason he chose not to.
To me, Bidenâ€™s attempt to promote the idea that Obamaâ€™s highest goal in life was for the U.S. to have a universal health-care system built on subsidized insurance exchanges reveals his low opinion of the Democratic electorateâ€™s intelligence.
Ben: Youâ€™re saying heâ€™s taking Obamaâ€™s favorite maxim, â€œDonâ€™t let the perfect be the enemy of the good,â€ a little too seriously?
Eric: Iâ€™m saying his implication is that Medicare for All is not desirable, because that would mean repealing the program that bears Obamaâ€™s name in popular discourse.
Ed: In reality, a majority of Americans probably really wish they could have private health insurance with no premiums, copays, or conditions. So everyone in both parties is trying to figure out a way to scratch that impossible itch. I agree that Bidenâ€™s formulation wonâ€™t satisfy much of anybody, but itâ€™s not as easy as it sounds.
Eric: I think â€œIâ€™m going to take what already exists and make it betterâ€ is a very popular line to draw. The question is exactly how much Bidenâ€™s plan would actually do to increase affordability for people who already have insurance.
Ed: I personally wish we could find a way to stop talking so endlessly and redundantly about health insurance and focus on price-fixing by providers.
Eric: Yes. The public is pissed about prices.
Ed: Weâ€™ll need to do that anyway to make single payer feasible.
Eric: The voting public likes universal coverage as an abstract principle. Thatâ€™s not a personal issue for the vast majority, but ever-rising premiums and deductibles are.
Ben: A topic for another day â€¦
Eric: â€œAll-Payer Rate Setting for Allâ€ just rolls off the tongue.